The Art of Living with Rheumatic Diseases

20 page brochure, Institute of Rheumatology, Ljubljana, Slovenia 2009

More Awareness but still no cure.  The Manja Zore project "The Art of Living with Rheumatic Diseases" was published as a 20-page booklet in observance of the World Arthritis Day in October 2009. The series was first exhibited at the National Assembly of the Republic of Slovenia and won Best Documentary Photo Series Award in the main Slovenian juried photography competition, Emzin Photo of the Year 2010.  It has since been presented at the RA Priorities event at the EU Parliament in Brussels, Belgium in 2011. 

Manja's photographic work has been exhibited internationally and appears in numerous books and magazines. Her photographs are part of the permanent collection of The Museum of Modern Art in Ljubljana, Slovenia.


Rheumatoid Nodule

A nodule is a local swelling or tissue lump, usually firm to touch.  They occur almost exclusively in association with rheumatoid arthritis. They are usually subcutaneous especially over bony prominences such as the tip of the elbow or olecranon or over the finger knuckles.

Nodules vary in size and are associated with synovial pockets or bursae.

  • about 5% of rheumatoid arthritis patients have such nodules within 2 years of disease onset, and the cumulative prevalence is about 25%. [1]
  • RA may cause symptoms because of pressure and location
  • they usually show up in people with more severe RA.
  • nodulosis occurs in 20-25% of patients with RA
  • cause inflammation of the peripheral joints. Destruction of cartilage. Erosive bone damage. Chronic pain. Deformity


    rheumatoid nodules are subcutaneous granuloma of lymphs and plasma cells

  • Cartilage is damaged by what enzyme that is released Collagenase

  • associated with strong seropositivity, implying aggressive disease with poor prognosis
  • may occur in benign form of RA manifested by nodulosis & mild polyarthralgias
  • nearly all cases are in people who have substances called rheumatoid factor and anti-cyclic citrullinated peptide antibodies in their blood. These are linked to inflammation.
  • one study found that cigarette smoking increases nodules in people with RA.
  • they may be more likely if your RA is extra-articular, meaning it affects body parts other than your joints. The most common are lungs and blood vessels. (Your doctor will call this vasculitis.)

Histology of nodules shows that they:

  • contain central area of necrotic fibrous & palisades of epithelioid cells inside of an outer zone of chronic inflammatory cells
  • consist of a shell of fibrous tissue surrounding a center of fibrinoid necrosis
  • pea sized nodules have one centrel
  • larger nodules tend to be multilocular, with many separate shells or with connections between the necrotic centres. Individual necrotic centres may contain a cleft or several centres of necrosis may all open on to a large bursal pocket containing synovial fluid
  • the boundary between the necrotic centre and the outer fibrous shell is made up of the characteristic feature of the nodule, which is known as a cellular palisade
  • the palisade is a densely packed layer of macrophages and fibroblasts which tend to be arranged radially
  • further out into the fibrous shell there is a zone that contains T lymphocytes and plasma cells in association with blood vessels
  • the overall histological picture is essentially identical to that of rheumatoid synovitis with the main differences being that the palisade replaces the synovial intima (they may blend imperceptibly in bursae) and an almost total absence of B lymphocytes

Treatment of rheumatoid nodules:

  • surgical removal is often successful, even if there is a tendency for nodules to regrow
  • Methotrexate has the disadvantage of tending to make nodules worse
  • TNF inhibitors do not have a very reliable effect on nodules
  • B cell depletion with rituximab often leads to disappearance of nodules but this is not guaranteed
  • not a priority unless erosion, pain, or infection present
  • cosmesis is factor if disfigurment of hand and forearms is major concern to patient
  • steroid injection can cause to regress, may cause ulceration of nodule
  • careful dissection of nodule from skin meticulous hemostasis necessary
  • protect nerves when applicable


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